A serious or sentinel event can, or has the potential to, cause serious lasting disability or death not related to the patient's illness or underlying condition.

Of the 17 incidents reported by the SCDHB, there was one suicide of a mental health patient who had taken an overdose of drugs before being readmitted to the hospital and another attempted suicide. Another patient was given too much medication.

The remaining 14 patients had falls.

SCDHB chief executive Chris Fleming said of those 14, five have since died, but it was not known if their deaths were directly a result of their fall.

Of the 14, 12 were in hospital because they had fallen or collapsed at home, including two long term Talbot Park residents.

Mr Fleming said all of the patients who did fall remained in hospital longer as a result. Some also required surgery to repair an injury sustained in the fall.

All but three of the patients who fell were over the age of 80.

Mr Fleming said the DHB was dealing with a large number of patients who were susceptible to falls.

However, latest figures were a concern, he said.

To limit the risk of falls among patients the DHB has adopted a range of procedures and trials.

Director of nursing, midwifery and allied health Jane Brosnahan said some of those included sensor mats, placed in mattresses, to alert hospital staff when a vulnerable patient is getting up.

Another product being used by patients is ‘grip socks'.

Nationally, 360 serious and sentinel events took place at public hospitals during the 2011-12 year, 91 of which resulted in patients dying.

The commission's chair Professor Alan Merry said not all the events described in the report were preventable, but many involved errors that should not have happened.

"In some tragic cases errors resulted in serious injury or death. Each event has a name, a face and a family, and we should view these incidents through their eyes." Many errors, Page 5